Cox � � ��������
APR 0 5 2012
NOTICE OF CLAIM FORM to the City of Saint P�l��ota
Minnesota State Statute 466.05 states that "...ever�•person...who claims damages from any municipality...shal/cause to be presented to the
governing bod}�of the munrcipality within 180 days after die alleged loss or injury is discovered a notice,rtating the time,place,and
circumstartces thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you wili not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something dces not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �Q rt.°Yl Middle Initial�Last Name ��`ix
Company or Business Name `���r�f15 �Yv►r n 15�Y�C.�f�Dr�
�
Are You an Insurance Company? Yes/(�To ) If Yes,Claim Number?
�} L./
Street Address ���.�(G Gt�'ro I 1 �'4- 4��
City -.X.I(YL'� �Q �� State m� Zip Code � ���`f"
Daytime Phone(�);3� - ���SCel] Phone( ) - Evening Telephone(65/ )�� /��o�
Date of Accident/Injury or Date Discovered �`�5 /%I Time �'�� �pm
Please state, in detail, what occurred(happened), and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
;rt �lt5f- 0►� rrcl �t`�- h T � ,' rt � . f/ � f �
.Srd�i.��f. /� ,F��c�'��r� /.s"�d 3 Q�2d /5,�5`
�c� ar� sc'�rr�/ Sr�cfi�,s a�' s�dr'.�u�r�.0 s�/��- �/�Uo�d � �",yi s�p'es e�i�
�G��'y- �rn� ���r• 6�� y�r�,�����/" Gr� ��r'�i��✓h���f.�u� dTlr�rs /4��nct
Please check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property
❑ Other type of property damage-please specify
� Other type of injury-please specify�'r2''cj�s �abr�s�cv►� a��a�e i�clud..r�6r-o,et'�� haS�-
In order to process your claim you need to include copies of all annlicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O I'roperty damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds$500.00; or the actual bills
and/or receipts far the repairs;detailed list of damaged items
b Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be retumed.
Page 1 of 2-Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease comulete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes � Unknown (circle)
If yes,what department or agency? ase#or report#
Where did the accident or injury take place? Provide street address,cross street. intersection,name of park or facility,
closest]andmark, etc. Please be as detailed as possible. If necessary, attach a diagram.
Please indicate the amount you are seeking in compensation or what you would,like the City to do to resolve this claim
to your satisfaction. �' �i � �i ( � t � / 5 � G � ' l �" � �
�d �,►' (;,� ,,<.
Vehicle Claims—please complete this section � check box if this section does not annlv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—nlease complete this section ❑ check box if this section does not applv
How were you injured?"7F���u t'G� � ,e„`��L�L/r��i%K
What part(s)of your body were injured? 7`'
Have you sought medical treatment? Yes _ No Pla in�to Seek Treatment(circle)
When did you receive treatment? '� �/� Gt i` '��� i (provide date(s)),
Name of Medical Provider(s): / ' C" S�� GL�`f'�T—�'4'�zi�'_✓'�-1 SPr' Cr�/ziuE-.��1�Ji/�S
Address Telephone
Did you miss work as a result of your in'ury? �' No
When did you miss work? � " / (provide date(s))
Name of your Employer: �.�rt �' � ►Z S + � _
Address � 5 . � � � c� c iS /�/Y ��it/� Telephone,G/Z '3y��-L,�"�
,
�Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed `� `� �'
Print the Name of the Person who Completed this Form: ��rU��7 ��G/1
Signature of Person Making the Claim: '�y"__L�7/1 ��•��.
Revised February 201 1
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'.... ALN-960 BPD'101-00607071-001274-01I01-0-0 � ..
Your Receipt
*************,�*********
Thank you for visiting!
***********************
Client: Karen Cox
Ticket: 77574
Monday, August 01, 2011
Description Price
-- - - _ _ _ __ _
E-Copay for Today's Date $15.00
Sub Total $15.00
sales tax $0.00
transittax $0.00
Grand Totai $15.00
Check $15.00
Change $0.00
*Come again soon*
. ' 028948
Connecticut Gerieral Life Insurance Company �
CIGNA HEALTHCARE,INC.
P.O.BOX 182223
CNATTANOOGA TN 37422-7223
CIGNA
Connecticut General Life Insurance Company AS AGENT FOR IKEA NORTH AMERICA SERVICES,LLC
Customer service
Call the number on the back of your ID card or
(800)244-6224(1.800.CIGNA24)
www.myCIGNA.com
KAREN A COX If you have any questions aboui this documeni,
1501 CARROLL AVE please call Customer Service ar the number
SAINT PAUL MN 55104-5303 above.Please have your reference number ready.
Service date
August 3,2011
THIS IS NOT A BILL. Reference#/ID
Your health care professional may bill you directly 7661122990166/U24858652
for any amount that you owe.
Account name/Account#
IKEA NORTH AMERICA SERVICES,LLC/
Explanation of benefits 3168712
for a claim received for KAREN A COX, Reference # 7661122990166
= Summary of a claim for services on August 3, 2011
=
- for services provided by THOMAS A OPHOVEN MD
= --- -----_---- -
� __ -- — ----- --------____
�N Amount B�llad $331.00 Thl,was the amount that was billed foryour visit on 08/03/2011-
�� — -------- --
�° Discount s65.90 You saved$65.90. CIGNA negotiates discounts with health care professionals and facilities to
�M help you save money.
°°° __ _
What CIGNA $250.10 �IGNA will pay$250.10 to THOMAS A OPHOVEN MD on 08/23/2011.
plan paid
_ _- .- ------
This is the amount you owe after your discount,what your CIGNA plan paid,and what your
What I owe accounts paid.People usually owe because they may have a deductible,have to pay a
$�5•00 percentage of the covered amount,or for care not covered by their plan. Any amount you paid
since care was received may reduce the amount you owe
__ _- _ _ - ---
You saved$316.00(or 95%)off the total amount billed.This is a total of your discount and what
your CIGNA plan paid.
You saved 95% To maximize your savings,visit www.myCIGNA.com or call customer service to estimate
treatment costs,or to compare cost and quality of in-network health care professionals and
facilities.
PLEASE SEE ClA1M DFTAILS�N PAGE 3_ v,,,�• �,�ra
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Connec[icut General Life lnsurance Company � 028950
CIGNA HEALTHCARE,WC.
P.O.BOX 182223
CHATfANOOGA TN 37422-7223
CIGNA
Connecticut General Life Insurance Company AS AGENT FOR IKEA NORTH AMERICA SERVICES,LLC
Customer service
Call the number on the back of your ID card or
(800)244-6224(1.800.CIGNA24)
www.myCIGNA.com
KAREN A COX
1 SO1 CARROLL AVE If you have any quesiions about[his document,
SAINT PAUL MN 55104-5303 please call Customer Service a[ihe number
above.Please have your reference number read y.
Service date
August S,2011
THIS IS NOT A BILL. Reference#/ID
Your health care professional may bill you directly 7661122990180/U24858652
for any amount that you owe.
Account name/Account#
IKEA NORTH AMERI�A SERVICES,LLC/
Explanation of benefits 3168712
for a claim received for KAREN A COX, Reference # 7661 1 229901 80
- Summary of a claim for services on August 5, 2011
=
- for services provided by MIDWEST SURG CTR
= __----------- ----- --— --- --- .. __ _--
�� Amount Billed $�,Q�2.00 This was the amount that was billed for your visit on 08/05/2011.
�N
�M .. __'___'"_"_._ _ "__' -_ _-
�� Discount $146.29 You saved$146.29. CIGNA negotiates discounts with health care professionals and facilities to
�m help you save money.
What CIGNA
plan paid $850.71 CIGNA paid$850.71 to MIDWEST SURG CTR.
This is the amount you owe after your discount,what your CIGNA plan paid,and what your
What I owe accounts paid.People usually owe because they may have a deductible,have to pay a
$15.�� percentage of the covered amount,or for care not covered by their plan. Any amount you paid
since care was received may reduce the amount you owe
_ ___ _-__
You saved$997.00(or 98%)off the total amount billed.This is a total of your discount and what
your CIGNA plan paid.
You saved 9$% To maximize your savings,visit www.myCIGNA.com or call customer service to estimate
treatment costs,or to compare cost and quality of in-network health care professionals and
facilities.
u
T
PLEASE SEE CLAIM DETAILS�N PAGE 3. n,,,� �„r�
' - 028951 �
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� Connecticut General Life Insurance Company � 028952
CIGNA HEALTK�ARE,INC i
P.O.BOX 182223
CHATTANOOGA TN 37422-7223 �
I
CIGNA
Connecticut General Life Insurance Company AS AGENT fOR IKEA NORTH AMERICA SERVICES,LLC
Customer service
Call the number on the back of your ID card or
(800)244-6224(1.800.CIGNA24)
www.my�IGNA.com
KAREN A COX
1501 CARROLL AVE If you have anyquestions abouc chis document,
SA I NT PA U L M N 5 5104-5 303 please call�usiomer Service at ihe number
above.Please have your reference number ready.
Service date
August 15,2011
THIS IS NOT A BILL. Reference#/ID
Your health care professional may bill you directly 7661 1 23090167/U24858652
for any amount that you owe.
Account name/Account#
IKEA NORTH AMERICA SERVICES,LLC/
Explanation of benefits 3168712
for a claim received for KAREN A COX, Reference# 7661 1 230901 67
= Summary of a claim for services on August 15, 2011
=
- for services provided by NANCY C TOKAR OTR
= - -- - - - - --
�N Amount Billed $244.60 This was the amount that was billed for your visit on 08/15/2011.
�� - --- ------
M
�° Discount $112.75 You saved$112.75. CIGNA negotiates discounts with health care professionals and facilities to
�m hetp you save money.
What CIGNA
plan paid
$116.85 CIGNA will pay$116.85 to NANCY C TOKAR OTR on 08R3/2011.
This is the amount you owe after your discount,what your CIGNA plan paid,and what your
What I owe $15.00 accounts paid.People usually owe because they may have a deductible,have to pay a
percentage of the covered amount,or for care not covered by their plan. Any amount you paid
since care was received may reduce the amount you owe
You saved$229.60(or 93%)off the total amount billed.This is a total of your discount and what
your�IGNA plan paid.
You saved 93% To maximize your savings,visit www.myCIGNA.com or call customer service to estimate
treatment costs,or to compare cost and quality of in-network health care professionals and
facilities.
�C
�L
PLEASE SEE CLAIM DETAILS ON PAGE 3. ���3<- i��f 4
� � 028953 �
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� Connecticut General Life Insurance Company � 003610
C��NA HEALTHCARE,INC.
P.O.BOX 182223
CHATTANOOGATN 37422-7223
CIGNA
Connecticut General Life Insurance Company AS AGENT FOR IKEA NORTH AMERICA SERVICES,LLC
Customer service
Call the number on the back of your ID card or
(800)244-6224(1.800.CIGNA24)
www.myCIGNA.com
KAREN A COX
1501 CARROLL AVE If you have any questions about this documeni,
SAINT PAUL MN 55104-5303 please call Customer Service at the number
above.Please have your reference number ready.
Service date
August 15,2011
THIS IS NOT A BILL. Reference#/ID
Your health care professional may bill you directly 7661 1 239901 29/U24858652
for any amount that you owe.
Account name/Account#
IKEA NORTH AMERICA SERVICES,LL�/
Explanation of benefits 3168712
for a claim received for KAREN A COX, Reference# 7661 1 239901 29
=
Summary of a claim for services on August 15, 2011
�
— for services provided by HEATHER L BERGESON MD
�
— --- --
�� Amount Billed $216.00 This was the amount that was billed for your visit on 08/15/2011.
�v ------ -- — —
=�� Discount $14.90 You saved$14.90. CIGNA negotiates discounts with health care professionals and facilities to
�m help you save money.
What CIGNA $186.10 CIGNA will pay$186.10 to HEATHER L BERGESON MD on 09/06/2011.
plan paid
This is the amount you owe after your discount,what your CIGNA plan paid,and what your
What I owe $15.00 accounts paid.People usually owe because they may have a deductible,have to pay a
percentage of the covered amount,or for care not covered by their plan. Any amount you paid
since care was received may reduce the amount you owe
You saved$201.00(or 93%)off the total amount billed.This is a total of your discount and what
your CIGNA plan paid.
You saved 93% To maximize your savings,visit www.myCIGNA.com or call customer service to estimate
treatment costs,or to compare cost and quality of in-network health care professionals and
facilities.
PLEASE SEE CLAIM DETAILS ON PAGE 3. N,��_�<�i�>r a
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� • • Connecticut General Life Insurance Company � 028954
CIGNA HEALTHCARE,INC.
P.O.BOX 182223
CHATTANOOGA TN 37422-7223
CIGNA
Connecticut Generai Life Insurance Company AS AGENT FOR IKEA NORTH AMERICA SERVICES,LLC
Customer service
Call the number on the back of your ID card or
(800)244-6224(1.800.CIGNA24)
www.myCIGNA.com
KAREN A COX
If you have any questions aboui ihis document,
1501 CARROLI.AVE please call�usiomer Service at ihe number
SAINT PAUL MN 55104-5303 above.Please have yourreference number ready.
Service date
August 1 S,2011
THIS IS NOT A BILL. Reference#/ID
Your health care professional may bill you directly 7661123090168/U24858652
for any amount that you owe.
Account name/Account#
IKEA NORTH AMERICA SERVICES,LLC/
Explanation of benefits 3168712
for a claim received for KAREN A COX, Reference # 7661 1 230901 68
�
= Summary of a claim for services on August 15, 2011
=
- for services provided by ABRAHAM S BAUMEL MD
= -------- - _--- — --- -- -- .__ ------ - - --- -- - __ .__
�M Amount Billed $63.00 This was the amount that was billed for your visit on 08/1 S/2011.
�ry
�!� --_"_..._'__"_"_'____-_--__
_"_"- --._...._ ____.-__"__'-_-- --
_�M
�° Discount $3.44 You saved$3.44. CIGNA negotiates discounts with health care professionals and facilities to
.�m help you save money.
What CIGNA
plan paid $44.56 CIGNA will pay$44.56 to ABRAHAM S BAUMEL MD on 08/23/2011.
This is the amount you owe after your discount,what your CIGNA plan paid,and what your
What I owe accounts paid.People usually owe because they may have a deductible,have to pay a
$15.�0 percentage of the covered amount,orfor care not covered by their plan. Any amount you paid
since care was received may reduce the amount you owe
You saved$46.00(or 76%)off the total amount billed.This is a total of your discount and what
your CIGNA plan paid.
You saved 76% To maximize your savings,visit www.myCIGNA.com or call customer service to estimate
treatment costs,or to compare cost and quality of in-network health care professionals and
facilities.
PLEASE SEE CLAIM DETAILS ON PAGE 3. N,j�a<• i�>f�
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. • � • •
�� 5100 Nortfiland Dc CheCk Credit card � �o�sc„ye� ��SA �+E
� Bloomington,MN 55431-4800 using for payment ❑ ` ❑ ', - ❑ ❑ �r+ESs
Card number Exp. date
� TRIAW Signature � Amount paid
StatemeM date Guarantor number Due date Pay this amourrt
� This statement includes services 10/02/11 T100397183 10/17/11 515.00
dated July 2, 2011 and later.
� Page 1 of 1 Q Online Services: Visit tria.com/billing to pay your bill online.
� -• .
� KAREN A COX TRIA ORTHOPAEDIC CENTER
e 1501 CARROLL AVE PO BOX 9157
m SAINT PAUL MN 55104-5303 MINNEAPOLIS, MN 55480-9157
o (�������������������������������������������������������������
000100397183000000D057000000000000150�5
Insurance patient Balance
Date Service description Charges payments 8� payments due
adjustments
SERVICE PROVIDED BY TRIA CLtNiC
PATIENT NAME: KAREN A COX
08/15/2011 TRIA HAND THERAPY $133.60
TOKAR, NANCY C
09/2�t/2011 CIGNA $118.60
BALANCE $15.00*
*Your insurance company has processed this claim and has determined the amount you owe. TOTAL BALANCE
Please contact your insurance company with any questions related to your balance due.
If you use your bank's online bill pay services, please update your guarantor account number and our MtNIMUM PAYMENT DUE
payment address as they have recently changed.This will ensure that posting of your Park Nicollet ��5.��
payment is not delayed. Call your bank if you need assistance.
t
t
Enterprise Payment Receipt
Serial # . . . . . . : 135143
Guarantor ID. . : 100397183 Guarantor Name . . : COX, KAREN A
Patient Name . . : COX, KAREN A Date . . . . . . . . . . . . : 09/20/2011
Department . . . . : TORTH TRIA ORT Amount Received : $15 . 00
8100 NORTHLAND DR
BLOOMINGTON,MN 55431
Details
Type Source Reference Payment Comment
Copay Check 15 . 00 15
����� kl
�
� � , , f
...�� ��'.. � p,l; ,. ' e'9
i
Total Amount : 15 . 00
Connecticut General Life Insurance�ompany � V��JJ�
. CIGNA HEALTHCARE,INC.
P.O.�OX 182223 '
CHATTANOO�ATN 37422-7223
CIGNA
Connecticut General Life Insurance Company AS AGENT FOR IKEA NORTH AMERICA SERVICES LLC
Customer service
�all the number on the back of your ID card or
(800)244-6224(1.800.CIGNA24)
www.myCIGNA.com
KAREN A COX !f you have any quesiions aboui ihis documeni,
1501 CARROLL AVE please call�usiomer Service at the number
SAINT PAUL MN 55104-5303 above.Pleasehave yourreference numberready.
Service date
September 20,2011
THIS IS NOT A BILL. Reference#/ID
Your health care professional may bill you directly 7661129090182/U24858652
for any amount that you owe.
Account name/Account#
IKEA NORTH AMERICA SERVICES,LLC/
Explanation of benefits 3168712
for a claim received for KAREN A COX, Reference# 7661 1 290901 82
=
= Summary of a claim for services on September 20, 2011
=
° for services provided by HEATHER L BERGESON MD
_
�= Amount Billed $144.00 This was the amount that was billed for your visit on 09/20/2011.
�A
__
�M
�^ Discount $�87 You saved S7.87. CIGNA negotiates discounts with heatth care professionals and facilities to
�� help you save money.
What your plan
paid $121.13 Your plan will pay$121.13 to HEATHER L BERGESON MD on 10/25/2011.
This is the amount you owe after your discount,Your plan paid,and what your accounts paid.
What I owe $15.00 People usually owe because they may have a deductible,have to pay a percentage of the
covered amount,or for care not covered by their plan. Any amount you paid since care was
received may reduce the amount you owe
You saved$129.00(or 8996)off the total amount billed.This is a total of your discount and what
your plan paid
You saved $9% To maximize your savings,visit www.myCIGNA.com or call customer service to estimate
treatment costs,or to compare cost and quality of in-network health care professionals and
facilities.
r
�
r
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�
PLEASE SEE CLAIM DETAILS ON PAGE 3. Page�of a
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